What is it?

Realism is the degree to which your simulation environment recreates or mimics the patient environment for your learners.

A word on fidelity.

The terms realism and fidelity are essentially interchangeable. However, many often associate the term fidelity with the amount of technology used to recreate the patient environment. For example, when educators refer to a case as “high fidelity” what they often mean is that they are using a costly computer-based mannequin with all the bells and whistles. The caveat, of course, is that having cutting edge equipment does not, on its own, ensure that the learner’s experience approaches reality. I prefer the term realism because it reminds us that there are more things to simulate than just the physical environment.

Why it’s important.

The basic premise of simulation as an educational modality is that it allows direct observation of a learner’s behaviour. Furthermore, debriefing in simulation allows discussion about noted learner deficiencies. Teasing out the learner’s cognitive process and knowledge gaps to discover the origins of the learner’s behaviour is paramount. In order to elicit true behaviour from a learner, (i.e. – behaviour that most closely mirrors their performance with real patients) the learner must treat the situation as a real one. And to do so, they must believe in it.

If the environment in which the learner is practising does not even come close to imitating reality, then the learner will not fully engage in the learning exercise. This limits the ability of the instructor to assess the learner’s abilities. In addition, not addressing realism lets learners use it as an excuse for their performance. For example, “If the mannequin had better breath sounds, I would have decompressed the tension pneumothorax.” Or “If this case was in the Emergency Department, I’m sure I would have seen the VT on the monitor and then shocked the patient.”

Making the environment mirror reality does not necessarily require high tech equipment. It does, however, require engaging the learners and addressing limitations to realism before the scenario begins. Orient learners to the mannequin so they know where they can feel pulses and where to listen for breath sounds. If the mannequin doesn’t have these things, let the learners know how to ask for physical exam findings. It is remarkable how well learners can engage in a scenario with a mannequin that has no high tech functions. They are only able to do this if you create conceptual realism.

Types of realism

In 2007, Rudolph, Simon, and Raemer described three different types of realism as essential to simulation training.1 Their terminology was a slight modification of Dieckmann’s work on the aspects of realism, also published in 2007. 2 The three components of realism highlighted by Rudolph et al are as follows:

1) Conceptual

Conceptual realism allows learners to think about a case in the same manner they would for a real patient. The most important component to creating conceptual realism is providing the learners with enough information to accurately frame the case. For example, you would expect a patient with a tension pneumothorax to have tachycardia, hypotension, and decreased breath sounds on one side. How this information is conveyed matters less than the fact that the information is logical in the context of the case.

To understand the power of conceptual realism, look to oral exams. The learner is able to make a diagnosis and manage a patient without any physical cues present. Oral exams can create conceptual realism. Conceptual realism is crucial to a good simulation scenario. And sometimes, adding too many bells and whistles actually takes away from the concept.

Yes, that’s right. You can be very low tech and still run fantastic simulation. You just need to set the stage, meet minimum cognitive standards, and debrief.

2) Physical

There are some things that just need to be practised in real time and space. Physical realism is most important for procedural skills. Practising airway management on an airway head that has unrealistic anatomy just doesn’t help learners to develop the motor memory they need. This doesn’t mean that all simulators need to be exact replicas. But to create physical realism, a task trainer must emulate the necessary motor feedback required to practise a skill properly. For example, a chest tube trainer doesn’t need to be an entire pig chest. It does, however, need to have an appropriate degree of resistance so that learners develop the sense of how hard to push in order to penetrate the pleura.

All mannequins have poor physical realism in some way. But with enough cognitive and experiential realism, it doesn’t need to affect the quality of the learning experience.

3) Emotional and experiential

This is the type of realism that puts a knot in your stomach. Experiential realism is about creating the emotions that often make our jobs difficult. Examples would include having a mother sob in the corner while trying to run a code on her infant child. Or having a difficult parent present who becomes obtrusive to care. Or how horrifying it can be to see a patient with a GI bleed exsanguinating from their mouth. Perhaps the challenge is creating the cognitive burden that goes along with managing two patients at once. Or perhaps the experiential realism comes from the frustration of dealing with a team that is obviously ignoring your direction. In other words, experiential realism is important to consider if the purpose of a case is to practice working through an emotionally challenging case or to teach techniques for overcoming a difficult family member or team member. It is also an important part of why junior learners can find simulation intimidating – because good experiential realism recreates the fear or discomfort that goes with being uncertain how to manage a particular condition. Again, your mannequin can be a cabbage patch kid doll if your sobbing parent actor is good enough.

The reality of realism

Realism is essential to simulation. As a simulation educator, you should be aware of which aspects of realism are most important for the case you are designing. Do you need to create an appropriate cognitive environment to assess the resident’s management of a TCA overdose? Do you need to see how the resident can lead a difficult team? Or do you need to see that a resident can skilfully perform a cricothyroidotomy? Or do you need all three components to assess a resident’s management of a pediatric trauma? Design your case and supplies with your realism goals in mind.


  1. Rudolph JW, Simon R, Raemer DB. Which reality matters? Questions on the path to high engagement in healthcare simulation. Simul Healthc. 2007;2(3):161-163. doi:10.1097/SIH.0b013e31813d1035.
  2. Dieckmann P, Gaba D, Rall M. Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc. 2007;2(3):183-193. doi:10.1097/SIH.0b013e3180f637f5.

PEM Review 003 – May 5th 2015

PEMgeek3Your weekly roundup of the best new paediatric #FOAMed resources starts here. Enjoy :)

1. OTITIS MEDIA Issues in acute OM: antibiotics, decongestants, antihistamines, pain relief? How much of your normal treatment strategy is backed up by good clinical evidence? Brilliantly short and digestible summary. @Cochrane_Child @TREKKca

fatigued adrenal glands2. ADRENAL CRISIS This week @pedseducation features the case of a child with septo-optic dysplasia who presents in adrenal crisis. What are the possible triggers for a crisis, and what do you need to consider when initiating urgent treatment?

 3. FALTERING GROWTH (What’s this doing on a PEM blog?) Hold on, keep reading! Yes, faltering growth is mostly worked up by paediatricians in general paeds clinics – but how do these kids come to their attention? Sometimes it’s only a chance ED presentation that will flag up these issues. This practice statement from the Canadian Paediatric Society gives an overview of faltering growth workup and makes it clear why it is so important to monitor growth opportunistically. @CanPaedSociety

    4. COMMUNICATION if you haven’t yet had to deal with a set of seriously peeved parents in the ED, you haven’t been working in EM long enough. Common sense strategies to de-escalate a potentially fraught scenario from @pemfellowscom .

sb   5. C BOTULINUM – a ‘D-list superbug'(!) Extremely rare, with a non-specific presentation, potentially life threatening, but treatable if detected early. (Who doesn’t occasionally dream of a ‘House’ moment?) Nice little article from @emdocsdotnet

 6. ‘HANDI’ TO KNOW Musgrove Park Hospital (@musgrovepark) in the UK has developed an app aimed at parents to help them manage common symptoms at home (fever, D+V, respiratory symptoms etc). It uses the ‘traffic light’ system (similar to the NICE guideline for fever in the under 5’s) to guide parents towards seeking further help if needed. It’s free to download, so it’s worth a look. Personally I feel it would be useful for parents of older children but advice for smaller ones is a little limited (ie, doesn’t make it clear that fever in under 3 months needs to be evaluated urgently by a doctor, not managed primarily at home) – perhaps future versions will address this.

  7. DKA: podcast of the week goes to this, from @EMcases. A detailed discussion of key issues in DKA, including really important points about fluid resuscitation (‘Don’t just do something, stand there…’) and how essential it is to FOLLOW A GUIDELINE. The podcast is an hour long so save it for when you have some time to kill.

        8. NOT ALL THAT SHAKES… is a seizure. If you have five minutes this is a great short piece that will help boost your differential diagnosis when things don’t quite fit. From @PedEMMorsels.
baby  And finally… Sometimes what we do day to day seems so routine – but over the past 40 years, there have been some incredible developments in the care we deliver to children. This video from @AmerAcadPeds highlights the importance of the paediatric research that has brought us to where we are today.
Keep visiting, new posts coming on a weekly basis!

Poner un supositorio: ¿nada es lo que parece?

La foto es de aquí
A mis cincuentaytantos voy y descubro ¡esto! No sé si cuando lo leáis pensaréis que soy tonta rematada pero yo siempre había pensado que el supositorio había que ponerlo por el lado puntiagudo y va y leo en el Bloc d' un Metge de Familia que es justamente al revés. Cuando hemos comentado este tema en un grupo de médic@s y enfermeras al que pertenecemos, ha habido de todo, pero las enfermeras estaban mejor informadas.
La información para la entrada la han obtenido de la respuesta a una pregunta recibida en Preevid. En fin, no es que haya estudios como para echar cohetes, pero al menos creo que hay como para una duda razonable...
Como curiosidad en la página de la que procede la foto, hablan también de lo mismo y hacen la misma recomendación.

#handwashing saves lifes

Hola a tod@s, my dear friends.

From Hospital Maciel of Montevideo in Uruguay, an old and dear friend, Dr. Fabio Grill shares with us an educational video about #handwashing.

During the whole today, today May 5th, World Day of #handwashing, activities will be carried out in the Patio del Brocal of the Hospital.

The proposal, embodied under the question "How does a surgeon wash his/her hands?", will allow these professionals interact with students from the public school.

During the event, surgeons will make a demonstration of the specific technique of hand washing in surgery, and will promote the importance of this practice of hygiene not only in health institutions, but also to the population in general in everyday life.

The objective of this Workshop which takes place everywhere, is raising awareness and sensitizing health teams, about the importance of improvements in the practice of hand hygiene to reduce health care-associated infections. More than 5000 hospitals and health centres in 127 countries have joined to this campaign of WHO.

Hand hygiene has been and continues to be one of the interventions more cost - effective against the transmission of diseases that are available in public health.

#safeHANDS has a great importance also for the population in general, as a way of preventing acute respiratory diseases and diarrhea, especially in children.

Share your initiative with the hashtag 
#safeHANDS  or #handwashing.

Happy Tuesday,

JellyBean 020 with Tim Duncan

Tim Duncan is a filmmaker. He is a doctor too but we’re not just doctors or nurses or paramedics are we.
Tim does a few very cool things. He has worked in a bunch of extremely cool places and this story starts in Catherine in the Northern Territory.
No CT. No MRI. No lots of things. But they did have Dr Tim.
Manuel and Tim star in a Critical Care Drama.
Cricket is in fact dangerous.
Tim talks us through an experience that might frighten you. It should. This is an experience that too many of our patients can relate to. Have a listen and put yourself in Tims shoes.

JellyBean Large

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HINTS Exam for Vertigo: Caveat Emptor


Hey all,

The March edition of Journal Club reviewed the HINTS exam for acute vestibular syndrome.  Much has been written/podcasted in the FOAM world about this controversial article, with the HINTS exam being touted as a godsend by some, while others recommend cautious use.  In addition to the usual critical appraisal of the article, journal club leaders Anthony Seto, Vanessa Potok and Andrew McRae also had us review the recommendations of 4 FOAM resources based on the HINTS article.  The FOAM recommendations were highly variable, to say the least. This post should be enlightening to many of us, and highlights the importance of actually reading articles yourself and critically appraising them, rather than implicitly taking advice based on the recommendations of a blog.

Article: HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging 

Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh, and David E. Newman-Toker. Stroke. 2009;40:3504-3510.


Image courtesy

Before getting into the nitty gritty, these are a few major reasons we should be cautious with use of the HINTS exam.

1)The definition of the acute vestibular syndrome (AVS) is continuous vertigo for > 24 hours. Ie: Not intermittent vertigo.  There is a very small subset of patients who actually have AVS, and in general we would likely have a higher index of suspicion for ominous causes in patients with continuous vertigo.  At journal club we agreed that many of us were applying this to patients with intermittent vertigo.  These patients were not included in the study.

2)This was done by a single neuro-ophthamologist using specialized equipment (Frenzl goggles) on a small number of patients (n=101) who were referred to a tertiary care stroke center from 25 community centres.  Most of us are not likely using Frenzl goggles in the ED, nor have we had specific training in this exam.  The study needs to be validated by EPs performing the exam in a typical group of patients presenting primarily to the ED.



Image courtesy

Here are the FOAM blog views on this article.

Blogs: ALiEM, BoringEM, EM Nerd, EP Monthly

BlogKey MessagesLimitations and InaccuraciesIf you had a “blog-based” practice, how would reading this SINGLE blog affect how you practice?
ALiEM“HINTS seems just as good as diffusion weighted MRI to diagnose posterior stroke”. INFARCT is acronym to use to remember central features on HINTS exam (Impulse Normal, Fast-phase Alternating, Refixation on Cover Test) The paper’s key message is that HINTS is better than MRI for ruling out stroke, rather than “just as good” to “diagnose” Since HINTS is as good as MRI, I would just use HINTS.
BoringEM Notes evidence for HINTS “very strong”. ONLY use for persistent and continuous vertigo.Proceed with HINTS exam with caution, since we don’t expect the same high sensitivity and specificity when used by non-expert clinicians.Okay to use HINTS < 24h, since the study enrolled patients >1h. Does not go into critically appraising the paper to support the statement that evidence is “very strong” I would only use HINTS for persistent/continuous vertigo, but only with caution, since I am not an expert in the technique
EM Nerd Head impulse hard to do and may produce vertebral artery dissection. 2013 HINTS versus ABCD2 acts as validation set. However, ABCD2 was not designed to differentiate between central versus peripheral, so of course HINTS would perform better. Specialist does HINTS. Small sample size. Very select population.In high risk patient, HINTS would be used to rule out central cause and symptoms.

HINTS could aid decision making process for low risk patients to help identify a subtle presentation of central vertigo.

Until HINTS is examined in ED, performed by ED docs, and on our patients, cannot know if any benefit and if it will contribute to clinical decision making.
Inaccuracy: “Sensitivity of 96%” is not acceptable to safety r/o central cause. It was the specificity that was 96%. Sensitivity was 100%. I will be cautious about performing HINTS until it is studied as performed by emergency docs on a less high risk population.
EP Monthly The people performing HINTS in the study were well trained (neuroophthalmologist, neurologist).

HINTS only if continuous vertigo.
Overall, pro-HINTS I need to make sure the residents in my program get trained in HINTS. Only trained people should use HINTS, but if trained, we should all be using it



Now let’s critically appraise the article.


  • Prospective, cross-sectional study performed at single urban, academic hospital serving as regional stroke referral centre for 25 community hospitals

Patients were recruited from the emergency department (n=59), other institutions (n=37), admitted patients with cerebellar infarctions (n=4), and one outpatient (n=1). A total of 101 patients studied, collected over 9 years. 65% were men with mean age 62 (range 26 – 92 years old).

  • Single neuroophthalmologist did HINTS exam on patients
  • HINTS exam was performed between 1 hour to 9 days from symptom onset (mean 26 hours). 75% were examined within 24h of symptom onset.
  • All patients underwent neuroimaging generally after bedside HINTS. If they had imaging prior to HINTS, examiner was blinded to these results at time of assessment. 70% were imaged within 6h of symptom onset. 97% were imaged within 72h of symptom onset.
  • All patients (including those with suspected acute peripheral vestibulopathy) were admitted for observation and serial daily examinations
  • Stroke diagnosis: MRI with DWI (97%) or CT
  • Acute peripheral vestibulopathy diagnosis: absence of stroke in brainstem/cerebellum on MRI with DWI, lack of neurological signs on serial exam, and characteristic clinical course, +/- caloric testing
  • Eight patients with initial negative MRI later underwent repeat MRI for unexplained neurological signs suggesting brainstem localization


  • One neuroophthalmologist conducted HINTS exam
    • HI = Head Impulse
    • N = Nystagmus
    • TS = Test of Skew
  • “Benign” HINTS = abnormal “HI”, direction-fixed “N”, and absent “TS”
  • “Dangerous” HINTS = normal/untestable “HI” or direction-changing “N”, or present/untestable “TS”


  • Core features of acute vestibular syndrome (rapid onset of vertigo, N/V, and unsteady gait +/- nystagmus). Note that duration of symptoms was not important to be included in the study, some patients had ~ 1 hr of symptoms prior to HINTS exam.
  • At least 1 stroke risk factor
    • Smoking
    • Hypertension
    • Diabetes
    • Hyperlipidemia
    • Atrial fibrillation
    • Eclampsia
    • Hypercoagulable state
    • Recent cervical trauma
    • Prior stroke
    • Prior MI



  • History of recurrent vertigo +/- auditory symptoms


  1. Determine diagnostic accuracy of skew deviation for identifying stroke in acute vestibular syndrome: compare proportions with skew deviation in peripheral versus central cases
  2. Determine added value of skew deviation beyond h-HIT: stratify results by horizontal head impulse test findings
  3. Compare HINTS exam’s sensitivity and specificity for presence of stroke


  1. Skew present in 17% of the 101 studied subjects and was associated mainly with brainstem lesions
    1. Skew in 4% (n=1 of 25) with acute peripheral vestibulopathy, 4% (n=1 of 24) with pure cerebellar lesions and 30% (n=15 of 50) with brainstem lesion (chi-squared, P=0.003)
  2. Skew correctly predicted lateral pontine stroke in 2 out of the only 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization (Table 3, below)
  3. Dangerous HINTS = 100% sensitive and 96% specific for central lesion (Table 4, below)


  1. Skew deviation is insensitive for central pathology but fairly specific for brainstem involvement for patients with acute vestibular syndrome
  2. Skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion
  3. HINTS appears more sensitive (100% for HINTS) and specific (96% for HINTS) than MRI with DWI in detecting stroke in first 24-48 hours after symptom onset


  • Internal validity
  • Pros
    • An appropriate reference standard was used initially: neuroimaging
    • Cons:
    • Partially unmasked examiner: although masked to results of imaging, was not masked to patient’s clinical history, general neurological exam, or obvious oculomotor findings
    • Selective MRI follow-up scans: MRI follow-up was only obtained for selected cases based on evolution of new neurological signs or atypical subtle oculomotor signs, potentially leading to the misclassification of strokes and acute peripheral vestibulopathy, increasing apparent sensitivity
    • Observer bias in interpretation of eye findings may inflate HINTS sensitivity
    • Unclear whether radiologist was blinded to HINTS exam results
    • Unclear whether there may have been other eye exam components that would be useful for predicting stroke and a validation study would be required if the current study functions as just derivation data
    • Relatively small sample size (N=101)
  • External validity
    • Pros:
    • HINTS is not very time consuming to do, and it is free
    • HINTS may be useful for the right patient population, i.e. active symptoms to avoid labeling a normal head impulse test as “central” in normal patients
    • Acute vestibular syndrome in the literature is defined as >24 hours. The study enrolled patients between 1 hour to 9 days. It seems to suggest that HINTS can be used for patients presenting as early as 1 hour after symptom onset.
    • Cons:
    • Generalizability of exam technique: HINTS was performed by a neuroophthalmologist and not by emergency physicians
    • Single examiner: unsure if testing style can be replicated by others
    • Restricted enrollment to high-risk patients: unclear whether results can be extrapolated to lower-risk population. However, there were some younger patients in the mix (15 were less than 50 y.o. and 6 were less than 40 y.o.). It was not clear which patients of what age had which risk factors, and if those combinations would make one at “lower” or “higher” risk.

It may have been useful to stratify patients into ataxic versus non-ataxic, since we are more concerned about what to do about patients who have less obvious neurological findings.

UCalgary Journal Club Group

These points were discussed during Journal Club on March 19, 2015:

  • In a patient with acute vestibular syndrome, who had a normal CTA and reassuring HINTS, would you send them home? 43% would consult neurology first. 57% would send the patient home.
  • Would you incorporate HINTS as an additional part of your physical examination? Most people agreed they would consider incorporating the HINTS components as part of their examination and, in particular, examining for high-risk nystagmus and skew deviation. There appeared to be agreement that the head impulse test may be challenging to perform, and we may not have adequate inter-rater reliability with a single, experienced neuro-ophthalmologist.
  • If you do use HINTS, ensure you use it on the right patient population: i.e. someone who has active persistent vertigo (acute vestibular syndrome patient) and not an intermittent vertigo like BPPV.
  • You may consider downloading a slow-motion camera application on your mobile device in order to detect the subtle ocular symptoms. However, the safety and accuracy of this practice has not been rigorously evaluated. Evidence in support of slow-motion applications is anecdotal at best, and its use is not recommended without evidence of its utility.
  • It may be challenging to differentiate between a normal versus abnormal head-impulse test. Moreover, an abnormal head-impulse test, although should imply a peripheral cause, can still mean a central cause. Therefore, direction-changing nystagmus and present skew deviation may be elements of HINTS less challenging to interpret.
  • Although there are many limits to the generalizability of the HINTS exam, if it can be conducted on the right patient population using appropriate technique, it may add to your overall diagnostic evaluation for patients with acute vestibular syndrome. Consider reviewing the HINTS exam:

There are many online resources and blogs that pertain to Emergency Medicine. Views may differ and there may often be limitations and inaccuracies. Remember to keep a critical mind when reading the online blogs and consult other resources as well as the primary source article.

Thanks again to Anthony Seto and Vanessa Potok for compiling this excellent summary.





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